pacify or orientate? Alzheimers...

So I have worked my third day as a LVN in a LTC facility. Orientated for one day then turned loose...on the alzheimers lock down unit. 21 residents.
A little scary, but I am fairly comfortable, so far. (should I be?)

Mrs. X is driving me crazy. For my three days she has asked to call her daughter to come get her.She is going home, looking for her car, easily agitated,etc.
The aides pacify her: "Mrs. X your daughter is at work, you can call her when she gets home from work" " your going home after lunch" This goes on all day.

I am new with Alzheimers behavior. I am new at being a nurse.
I don't feel good about telling her she can call her daughter to get her
"after she gets off work" , or that she is going home.
Is this not implanting the idea even futher, possibly even creating a cycle?
Any advice/ suggestion?

I worked as the LPN/Care Coordinator in a Memory Care Unit for residents with Alzheimer's and dementia. Actually your aides are doing the right thing. There are wonderful books on how to talk to alzheimer residents out now that say basically the same thing. I have several, which I packed up, since we are moving. I ordered them from Amazon. These books really helped. I'll look and see if I can get the names of them for you.

Number one rule, don't try to argue with a resident with alzheimer's. You will never win. Also a person with alzheimer's can't remember asking you about her daughter, or what day it is. In fact she or he will forget they asked a few minutes after they ask. Orientation really doesn't help much, due to the short term memory loss. They can remember what happened 20 or 40 years ago, but not what they had for lunch or even if they had lunch yet. Plus they are often living in a time in the past. We had a excellent support group at our facility, we learned alot about how to live in the residents moment, not ours.

When I worked in the unit, one little lady would wheel into my office with here wheelchair and ask me to make a reservation for two, I would answer her by saying, "Okay "Sally" I just made your reservation for two." She would smile and say thank you and go on her way. This would happen 5 to 10 times each day, but it only lasted a few seconds and she was happy.

Working with Alzheimer's resident takes patience, yet it is so rewarding. I do miss the unit and hope to work with alzheimer's residents when my husband and I move to Tennessee.

Aug 28, '06

I agree -- if you can get ahold of Naomi Feil's work, which basically says you have to be with them where they are in that moment. They cannot step into your reality, so you must step into theirs. Redirect behaviors if you can -- try an activity, music, or group led activity that is going on on the unit. If not, just go with the flow.... smooth sailin' that way.

Aug 28, '06

I like the term "therapuetic lying". Like the others have said.. YOU WILL NOT WIN and you will NOT convince them that their mother is not waiting for them outside. Often times "reality orientation" only serves to agitate a resident. Ya just gotta go with the flow and redirect their attention. My all time favorite was a 105 YO large german lady. Every day around 3pm she would try to elope cuz she had to go out and milk the cows. Front office staff, some CNA's, etc always tried to convince her there were no cows. This would eventually lead from cussing to hitting at the staff. Me, I would run out a side door - back into the front door exclaiming to the german lady "Oh my gosh, I am so tired from milking all the cows today can you help me find a cup of coffee so I can rest a bit". Worked every time - she was just thrilled that someone did milking duty for her.

Aug 28, '06

The cow story is wonderful. Thanks for giving me valuable information. I am always looking for info on dealing with our confused patients.

Aug 28, '06

Hello
I too work in LTC as an aide, going to school for nursing, I also take care of my 76 year old mother with dementia at home, as far as the others have said they are right, you have to live in their moments, sometimes you have to talk to them at their level which sometimes means like a child, save yourself argument and agitation......go with the flow........or just agree with them, in a few moments or so they won't remember, but it will satisfy them for the time being, and yeah it can be quite repititious and demanding but usually you can always think of something that they want to hear that pacifies them and then move on.

Theresa

Aug 28, '06

Quote from Nascar nurse

I like the term "therapuetic lying". Like the others have said.. YOU WILL NOT WIN and you will NOT convince them that their mother is not waiting for them outside. Often times "reality orientation" only serves to agitate a resident. Ya just gotta go with the flow and redirect their attention. My all time favorite was a 105 YO large german lady. Every day around 3pm she would try to elope cuz she had to go out and milk the cows. Front office staff, some CNA's, etc always tried to convince her there were no cows. This would eventually lead from cussing to hitting at the staff. Me, I would run out a side door - back into the front door exclaiming to the german lady "Oh my gosh, I am so tired from milking all the cows today can you help me find a cup of coffee so I can rest a bit". Worked every time - she was just thrilled that someone did milking duty for her.

I use this kind of redirecting all the time. I learned this with my grand mother.
My great aunt and I went to see her one day and granny said she had just gotten home from a wonderful time in Galveston. She was bedridden in a ltc at the time. My Aunt began to correct her and attempted to reorient her I was a nurse at the time and stopped her. and then asked Granny How is the weather there and was it too windy. and she began to tell me stories of when she was a girl in galveston.
My aunt was furious and raled at me for an hour. I didnt care My Granny and I had a great day at the beach.

Aug 29, '06

"Therapeutic lying" is absolutely inappropriate. It is unethical and in my opinion, it implies pure laziness on the Nurse's part. Telling the patient what you think 'they want to hear' does nothing for them therapeutically.
It's sad that so many Nurses just take the easy way out by 'pacifying' these people.

"Think of a time you've been lied to. Say your 12year old son said he would be at his friend's house but in reality he went to park to skate with a bunch of kids you don't know. You most likely would be upset that your son lied. If you had dementia, however, you may never remember your son saying where he'd be. He gets home and says, "I had a great time at the park." Whether or not you remember does not change the fact that he lied. It is no different when speaking to a client (patient). They may not remember their daughter isn't coming to get them, but it doesn't change that you lied to them."

Continue to re-orient your client. Why? It's respectful, it helps combat dementia, and redirecting can help rebuild short term memory.

P.S. The correct term is 'orient,' NOT 'orientate.'

Aug 29, '06

Lfransis,
Congrats with your new job. It will be fun and challenging! I would also like to recommend you read some of Naomi Feil's work. One great book is called The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimer's Type Dementia. The techniques are great for all types of dementia. Reorienting a moderate to advanced dementia patient is often NOT therapeutic and can be counter productive. For example: the 83 y.o. woman who repeatedly asks where her husband is because she's forgotten he passed away 3 years ago. Reorienting her to this fact over and over again puts her through trauma and isn't going to help her remember in the long term. Of course you're always going to want to do some basic reorientation as it seems appropriate. However, Jesskanurse is incorrect in stating that it combats dementia. Working with moderate to advanced dementia patients is mostly going with the flow and helping them exist in their reality. "Theraputic Lying" or what ever you want to call it is not unethical and I don't think it further implants ideas. It is a well-supported method of working with dementia patients. Redirection will also be your friend when working with these folks and is often more apppropriate than reorientation but it will not rebuild short term memory.

Aug 29, '06

Quote from Jesskanurse

"Therapeutic lying" is absolutely inappropriate. It is unethical and in my opinion, it implies pure laziness on the Nurse's part. Telling the patient what you think 'they want to hear' does nothing for them therapeutically.
It's sad that so many Nurses just take the easy way out by 'pacifying' these people.

"Think of a time you've been lied to. Say your 12year old son said he would be at his friend's house but in reality he went to park to skate with a bunch of kids you don't know. You most likely would be upset that your son lied. If you had dementia, however, you may never remember your son saying where he'd be. He gets home and says, "I had a great time at the park." Whether or not you remember does not change the fact that he lied. It is no different when speaking to a client (patient). They may not remember their daughter isn't coming to get them, but it doesn't change that you lied to them."

Continue to re-orient your client. Why? It's respectful, it helps combat dementia, and redirecting can help rebuild short term memory.

P.S. The correct term is 'orient,' NOT 'orientate.'

No experience working with dementia/alzheimers patients huh? Been doing this over 20 years. The staff the insist on reality orientation gets cussed, hit, bit, spit at, etc and the resident can become agitated beyond belief. The staff the goes w/ the therapuetic lying ends up with calm happy residents. Lazy?? Takes alot more energy to be running around a building pretending to milk cows then just say "There are no cows out there" and walk away.

Aug 29, '06

Quote from Jesskanurse

"Therapeutic lying" is absolutely inappropriate. It is unethical and in my opinion, it implies pure laziness on the Nurse's part. Telling the patient what you think 'they want to hear' does nothing for them therapeutically.
It's sad that so many Nurses just take the easy way out by 'pacifying' these people.

"Think of a time you've been lied to. Say your 12year old son said he would be at his friend's house but in reality he went to park to skate with a bunch of kids you don't know. You most likely would be upset that your son lied. If you had dementia, however, you may never remember your son saying where he'd be. He gets home and says, "I had a great time at the park." Whether or not you remember does not change the fact that he lied. It is no different when speaking to a client (patient). They may not remember their daughter isn't coming to get them, but it doesn't change that you lied to them."

Continue to re-orient your client. Why? It's respectful, it helps combat dementia, and redirecting can help rebuild short term memory.

P.S. The correct term is 'orient,' NOT 'orientate.'

So how many years have you worked in LTC? I'll bet almost none?
The lazy and innappropriate/ illegal way to do it is to restrain and medicate. Fortunatly for my pts this is not an option. I can go on and on about why you are wrong on so many levels, but I'll just let you see how far you get with telling "the truth" to your demented patients.

Aug 29, '06

Validation therapy is the best approach. I am the Dementia Care Coordinator in my facility and am constantly in-servicing staff and family members about the best approach to communicating with individuals with dementia. Sure, "therapuetic lying" is very easy if you're rushed and can get you short term results, but I believe that it is unethical and bases the relationship on deciet. It indicates a lack of respect for others and doesn't address the real issue--the resident who is looking for her mother or wants to go home to make dinner is feeling something; scared, abandoned, worried, lonely. Validation therapy explores this and validates a resident's feelings.

An anecdote: A resident named "Betty" gets anxious and agitated in the late afternoon and attempts to leave the activity group and try to go down the elevator to "get a recipe from her aunt". This behavior is dangerous because she usually falls right around the same time and is difficult to monitor outside of the activity group. I spent five minutes talking to "Betty" about the recipe, the aunt, reminiscing until somehow the conversation got to how "Betty" used to be a phone operator. By using validation techniques on her, "Betty" was left feeling validated, sat back and relaxed and exhibited no further behaviors for the rest of the evening.

I am sure most of you will say, "But I don't have time to talk to her for five minutes!" I will say that that staff don't have time to drag her wheelchair back to the activity every two minutes for 3 hours while she anxiously calls out and cries. The nurse doesn't have time to fill out the incident report when she falls which requires a call to the MD and family. Then I don't have time to fill out the incident investigation and interview everyone involved, update care plans, ect.. It only took five minutes to make the resident feel better and save everyone else a lot of work.

As far as reality orientation, I will just say that it might work for some early stage dementia if the resident asks for it, "what time is it? where am I?" Subtle cues like calendars, clocks on the wall might have meaning for some early stage people.

Great thread!

Aug 29, '06

Quote from romie

Validation therapy is the best approach. I am the Dementia Care Coordinator in my facility and am constantly in-servicing staff and family members about the best approach to communicating with individuals with dementia. Sure, "therapuetic lying" is very easy if you're rushed and can get you short term results, but I believe that it is unethical and bases the relationship on deciet. It indicates a lack of respect for others and doesn't address the real issue--the resident who is looking for her mother or wants to go home to make dinner is feeling something; scared, abandoned, worried, lonely. Validation therapy explores this and validates a resident's feelings.

An anecdote: A resident named "Betty" gets anxious and agitated in the late afternoon and attempts to leave the activity group and try to go down the elevator to "get a recipe from her aunt". This behavior is dangerous because she usually falls right around the same time and is difficult to monitor outside of the activity group. I spent five minutes talking to "Betty" about the recipe, the aunt, reminiscing until somehow the conversation got to how "Betty" used to be a phone operator. By using validation techniques on her, "Betty" was left feeling validated, sat back and relaxed and exhibited no further behaviors for the rest of the evening.

I am sure most of you will say, "But I don't have time to talk to her for five minutes!" I will say that that staff don't have time to drag her wheelchair back to the activity every two minutes for 3 hours while she anxiously calls out and cries. The nurse doesn't have time to fill out the incident report when she falls which requires a call to the MD and family. Then I don't have time to fill out the incident investigation and interview everyone involved, update care plans, ect.. It only took five minutes to make the resident feel better and save everyone else a lot of work.

As far as reality orientation, I will just say that it might work for some early stage dementia if the resident asks for it, "what time is it? where am I?" Subtle cues like calendars, clocks on the wall might have meaning for some early stage people.